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DUODENAL SWITCH
What you need to know
What is Duodenal Switch?
• Duodenal Switch (DS)
• “double anastomosis” or classic DS
• “single anastomosis”
What is Duodenal Switch?
• DS (single and double) are alternative
procedures to traditional gastric bypass and
sleeve gastrectomy
• May be offered on a highly selective basis
when potential benefits clearly outweigh risks
• Very few surgeries at St Joe’s are DS
Why Consider Duodenal Switch?
• DS offers the best chance of
improvement/remission of type 2 diabetes
• DS can offer slightly better weight loss than
sleeve or bypass
• DS has a lower chance of weight regain in the
long-term
Why Consider Duodenal Switch?
However…
Why Consider Duodenal Switch?
• DS also has the highest level of surgical risk
• Often done as two surgeries
• DS requires significantly more attention to
prevent malnutrition
• DS has potential for significant side effects
Who May Be Eligible?
• Patients with severe diabetes that is difficult
to control
• Patients who have had a sleeve but who
could benefit medically from additional
weight loss.
• Patients with significant weight regain after
sleeve or gastric bypass
Who is Not Eligible?
• People with inflammatory bowel disease (Crohn’s disease, ulcerative colitis)
• People with severe/frequent diarrhea
• People with severe and unmanaged psychiatric illness
• Age over 60 years old
• Many other patient-specific reasons may also rule out a DS
Normal Anatomy
• Food travels down the esophagus to the stomach
• It then goes into the small intestine and then the large intestine
• Digestive juices travel with your food to help absorption
Duodenal Switch
(double anastomosis)
Duodenal Switch
(double anastomosis)
• Creation of small stomach shaped like a sleeve
• Small intestine is disconnected from sleeve
• Lower part of small intestine attached directly to sleeve
• Large amount of small intestine bypassed
Image source: Ethicon Endo-Surgery, INC.
Duodenal Switch
(double anastomosis)
Image source: Ethicon Endo-Surgery, INC.
• Smaller stomach means
you feel full faster
• Hormonal/metabolic
changes lower your
appetite
• Do not absorb all of your
calories
• Do not absorb
vitamins/minerals
properly
Duodenal Switch
(single anastomosis)
Duodenal Switch
(single anastomosis) • Creation of small
stomach shaped like a
sleeve
• Small intestine is
disconnected from
sleeve
• Loop of small intestine
attached directly to
sleeve
• Smaller amount of small
intestine bypassed
• Common channel longer
than with DS
Duodenal Switch
(single anastomosis)
• Smaller stomach means you feel full faster
• Hormonal/metabolic changes lower your appetite
• Do not absorb all of your calories
• Do not absorb vitamins/minerals properly
Single vs Double Anastomosis
Single
• One connection
• Less risk
• Longer common channel
• (~250-300 cm, ~ 8-9 ft)
• Less malabsorption
• Fewer side effects
• Less research
Double
• Two connections
• More risk
• Shorter common channel
• (~100 cm, ~ 3 ft)
• More malabsorption
• More side effects
• More research
Bypass/Sleeve vs DS
Bypass/Sleeve
• Slightly less weight loss
• ~15-30% have weight regain
• Lower malnutrition risk
• Fewer side effects
• 7-9 pills/day (vitamins)
DS
• Slightly more weight loss
• ~10% have weight regain
• Higher malnutrition risk
• More side effects
• 13-15 pills/day (vitamins)
One Surgery or Two?
• If you have never had bariatric surgery:
• Usually done as two surgeries
• Can be done in a single-stage for select patients
(up to surgeon)
• If you previously had sleeve gastrectomy:
• DS is done as one surgery
• If you previously had gastric bypass:
• Typically done as two surgeries
Weight Loss
• Weight loss with DS is typically around 30-40% of
highest body weight when performed as a single-
stage or as an early second-stage
• Can be less when performed as after significant
weight regain with sleeve or bypass
• Is typically slower than with bypass or sleeve
• As always, health improvements are more
important than body weights
Side Effects
• Most people have more frequent bowel movements
• Soft or loose bowels
• Most people will have a BM 2-4 times per day but can be up to 10 times per day for the first 12-18 months
• Eating a very high fat meal can cause very bad diarrhea
• Many people complain of frequent and foul smelling gas
• Less common with single anastomosis
• Can be controlled to some extent through diet
• Worse with simple sugars and carbohydrates
Vitamin/Mineral Supplementation
Option 1 Option 2
Multivitamin High ADEK multivitamin
3x/day
Adult multivitamin
2x/day
Calcium 500-600 mg 3x/day 500-600 mg 3x/day
Iron 300 mg ferrous sulfate
1x/day
300 mg ferrous sulfate
1x/day
Vitamin B12
1000 mcg tablet 1x/day
OR
1000 mcg IM injection
1x/month
1000 mcg tablet 1x/day
OR
1000 mcg IM injection
1x/month
Vitamin A n/a 10,000 IU/day
Vitamin D 2000 IU/day 2000 IU/day
Vitamin E n/a 400 IU/day
Vitamin K n/a 300 mcg/day
Vitamin/Mineral
Supplementation Schedule Time Option 1 Option 2
Morning
ADEK multivitamin
Calcium
Vitamin B12
Calcium
Vitamin D
Vitamin A
Vitamin B12
Afternoon
ADEK multivitamin
Calcium
Vitamin D
Calcium
Vitamin D
Vitamin E
Evening
ADEK multivitamin
Calcium
Vitamin D
Calcium
Vitamin K
Bedtime Iron Iron
Multivitamin(s)
Total # Pills 13 15
Dietary Guidelines
• Protein goal is much higher
• ~120 grams per day (don’t absorb all)
• Need to eat protein 6 times per day
• Usually includes one protein shake per day
• Need to eat more calories than with
bypass/sleeve
• Don’t absorb them all
• Diet is relatively higher in protein and healthy
fats, and slightly lower in carbohydrates
Dietary Guidelines - Example Breakfast: omelette (2 eggs + 1 oz ham + onions/peppers/mushrooms) + 1 slice toast with ¼ avocado (smashed)
AM Snack: ½ cup 2% cottage cheese + 2 melba toast
Lunch: chicken salad wrap (4 oz chopped chicken + full fat mayo/green onion/celery + romaine + tortilla)
PM Snack: 2 oz cheddar cheese (regular) + 2-3 melba toast
Dinner: 4 oz salmon + ½ cup green beans + ¼ cup quinoa
HS Snack: ½ cup 2% plain Greek yogurt + ½ cup berries + 2-3 tbsp chopped nuts
Mental Health and DS
Common Mental Health Issues
• Eating Disorder History
• Trauma History
• Depression and Anxiety
• Substance Use (risk of post-addiction transfer)
• Body image concerns
• Self-harm, suicidality
• Important to have stability with symptoms • Specific guidelines and intervention for issues
such as substance use, inpatient admissions, suicide attempts, changes to medication etc.)
Mental Health and DS
Psychotropic Medication
• Understanding of absorption
• Follow-up monitoring for medication (e.g.,
adjustments)
• Closer monitoring of symptoms and stability
• Having a post-op care plan (e.g., family
physician, mental health resources)
Mental Health and DS
Adaptive Coping Strategies
• How to navigate difficult situations
• Regimented, ability to follow structure and routine
• Evaluation of significant stressors and strategies to reduce/manage stressors
• Importance of social supports and ability to access supports
• Compliance and motivation
Mental Health and DS
Social Issues
• Financial stability for costs associated with surgery
• Home life stability
• Open to accessing community resources
What If You Don’t Want DS?
• If you decide that you don’t want DS but are still
interested in other treatments, you could consider
medications instead
• SAXENDA (liraglutide) DIN # 02437899
• Daily injectable medication
• Suppresses appetite and increases fullness
• CONTRAVE (naltrexone HCI/bupropion HCl) DIN #
02472945
• Daily oral medication
• Suppresses appetite and food cravings
GETTING READY FOR
SURGERY
Before Surgery
• You will be assigned to a nurse navigator and
may meet them in person, or they may call you
over the phone
• Nurse will arrange your appointments and
testing
• Have many tests to make sure you can safely
have surgery. You may have:
•Gastroscopy •Ultrasound
•Sleep study •Blood tests
•Barium Swallow •Electrocardiogram
Before Surgery • You will attend many appointments to see members of the health care team. You will see the:
• Medical Internist
• Social Worker and/or Psychologist – sometimes several times
• Dietitian – you will have several appointments
• Surgeon
• Appointments will be on different days
• If appointments are on the same day you may have to wait between appointments
Before Surgery
• Team members will assess:
• your risks and benefits and may determine
whether DS is offered to you
• your knowledge and understanding of DS
• your ability to follow lifestyle
recommendations for DS
Missed Appointments
• If you miss 2 appointments without notifying
the clinic your name will be removed from the
list of candidates for surgery.
• Important to always notify clinic if you cannot
make an appointment
• There are many people waiting for
appointments
Before Surgery
• Stop smoking NOW! You must be 6 months smoke-free before your assessments start.
• This includes all forms of nicotine (e-cigarettes,vaping, Nicorette gum etc.)
• Smoking significantly increases your risks for surgery (poor healing and ulcers)
Preparing for Appointments
• If you previously had gastric bypass or sleeve gastrectomy at another hospital, we may need you to retrieve your operative note from that institution
1. Ask your nurse whether we can get it or not
2. If not, contact their Health Records Department
3. Ask if they still have your operative note on file
4. Will likely need to pay a fee
5. Obtain a paper copy of the report and bring with you to the clinic
What’s Next?
• How to let us know…
Resources
• Duodenal Switch Handbook
• Single anastomosis DS handout
• www.dsfacts.com
• Youtube:
• Search “duodenal switch animation” for
double anastomosis DS video
• Search “loop duodenal switch procedure”
for single anastomosis DS video
Getting Ready for RD
Appointments
• Review all resources provided
• Bring the following:
• At least 7 days of food records
• Bring “Getting Ready for Your DS
Assessment” worksheet
• Bring Duodenal Switch book and single
anastomosis DS handout
Questions